We Performed A Difficult "3rd Revision Rhinoplasty Operation"

Tertiary Nose Job in Men

3rd Revision Rhinoplasty Operation in Istanbul

The patient, who had undergone nose aesthetic surgery twice before, presented to us with nose deformity and breathing problems on the nose. In the case I presented here, the asymmetric appearance of the nasal bone, Inverted-V deformity, hanging columella, droopy nasal tip and notched nose wings are seen in the preoperative photograph. Right nose bone wall slighly angled outward. We reconstructed the nasal tip and nasal bone using rib cartilages during surgery. As can be seen, the tip of the nose is slightly droopy and long; we reduced the nose tip projection . Bilateral spreader grafting and nasal bone fracture (osteotomy) were performed on the right side. Revision nose surgeries involves differences from primary surgery. Tissue plans are often narrowed, cartilage and bone tissues that are very valuable to us have been removed excessively or asymmetrically, and the forces during healing twisted weak or weakened cartilages. This requires more careful and gentle operation during surgery. Skin and soft tissue revision is very important in rhinoplasty.

Augmentation nose aesthetic operation

As seen in the photographs, the nose looks shorter when viewed from the front, but it is seen from the side that the dorsum with increased nasal volume (in fact, we tried to place the removed tissues on the nose in previous surgeries, in other words, augmentation rhinoplasty was performed). While it is quite easy to remove tissue from the nose; it is rather difficult to create tissue instead of doing the same. While it is easy to shape a bone or cartilage tissue; it is not easy to do the same or replace it. Rib cartilage was used because there was not enough cartilage in the nose of the patient.

Revision rhinoplasty often requires grafts. Nasal septum cartilage is often used or insufficient because of previous surgery. In this case, it may be necessary to remove cartilage from the ear or ribs as needed. In such a case, the duration of the operation is further extended.

The sharp, long and droopy nose tip has been replaced by a natural and more masculine-looking nose tip. When viewed from the front, the right wall of the nasal bone is further out in the preoperative photograph. During the operation, osteotomy was performed on the right nasal wall and the nasal bone was medialized and made similar to the left nasal wall. Since there was not enough cartilage at the tip of the nose, a support cartilage graft was placed at the tip of the L-shaped cartilage graft. The picture shows the nose shape after 10 days. The brown appearance on the edges of the nasal skin depends on the temporary brown discoloration left after the Arnica Montana gel used after surgery.

Cartilage grafts are needed in revision rhinoplasty operations

Grafts; are the structural elements we use from time to time to shape the nose. When necessary, I use the cartilage of the septum provided that it does not disturb the nose support, or the rib cartilage I received from the person in the major revision if the ear is not sufficient or structural support is required. In primary rhinoplasty, almost all of the graft needs can be obtained from septum cartilage, while revision rhinoplasties usually require ear or rib cartilage depending on the extent of deformity.

3rd Revision Rhinoplasty Operation in Istanbul

It is seen that the right upper lateral cartilage of the patient is very weak during surgery and there is significant "inverted V deformity" especially on the right side due to the gap in that area. Postoperative photographs show that some of the soluble sutures in the columella have stopped. In an average of 2 or 3 weeks, all of these stitches fall off by themselves. During the procedure, "alar base resection" was performed as alar plasty procedure. A few millimeters of alar base resection made from the inside provides vertical erection and contraction of the nose wings.

3rd Revision Rhinoplasty Operation in Istanbul

Functional Evaluation Before Revision Rhinoplasty

When the preoperative photographs of the patient are examined, collapse of the nasal valve region and weakness of the nasal wings are easily understood. Bilateral spreader graft and columelllar strut graft placed during the operation provided enlargement in the narrowed area in the nasal valve area and relief in the obstructed airport in the nose. The purpose of the surgery here is not only aesthetic reasons; it is the ability to improve the nose in both cosmetic and functional terms. In this way, it is very important that the triangle in the nose looks natural and also that there is no collapse of the nose wings. Especially in patients with weak nasal wings (nasal vaşve collapse) during rapid breathing, collapse of the nose wing and severe short-term obstruction or blockage of the nasal airway may occur. Static and dynamic valve collapse is common in revision rhinoplasty patients. Nasal side wall stenosis and collapse of the nasal wings while breathing are prominent features of nasal valve constriction. Observing the patient during normal and deep breathing may make a direct diagnosis. The modified cottle maneuver (subjectively improved patient breathing when the nasal sidewall is supported by the cuff curette) supports the diagnosis.

3rd Revision Rhinoplasty Operation in Istanbul

3rd Revision Rhinoplasty Operation in Istanbul

Please note that there are several factors that make your expectations difficult (perhaps the perfect result of your nose) in revision rhinoplasty operation:

- surgically modified anatomy
- hardened tissue healing (decreased circulation)
- the presence of suture reactions and prior wound healing tissues
- insufficient cartilage or bone tissue
- operation planning can only be made according to the details that can be understood during the operation

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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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